That Others May Live?

Even with an uncontrolled addiction and a volatile supply of opiates, Hoffman was able to maintain a schedule and rate of productivity that would be challenging for most sober people. But that speaks to heroin’s chief paradox—while its use is less likely to publicly stigmatize you as an addict through erratic behaviors, it’s far more likely to kill you. Virtually every celebrity overdose involves some kind of opiate trigger.

The uncertain legacy of Philip Seymour Hoffman

February 11, 2014

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One day on the set of Charlie Wilson’s War, seven years before he died alone in a West Village bathroom, the great Philip Seymour Hoffman contemplated the likely consequences of his own death. “If one of us dies of an overdose, probably 10 people who were about to won’t,” Hoffman told screenwriter Aaron Sorkin, who himself had struggled for years with cocaine abuse.

Celebrity deaths undeniably have consequences, particularly when the rich and famous are victims of larger trends already sweeping up the less powerful. When Rock Hudson died of AIDS in October 1985, millions of fans around the world awoke to the crisis—including First Lady Nancy Reagan, who pushed her husband’s administration to heed requests for additional funding for AIDS research. A celebrity death can also have negative consequences, like giving cover to a punitive justice system. The following year, 22-year-old college basketball star Len Bias died of a cocaine overdose just hours after being drafted by the Boston Celtics. Bias’s death, which came just as the urban crack epidemic was starting to explode, directly led to passage of the Anti-Drug Abuse Act of 1986 (also known as the “Len Bias Law”) that established severe mandatory minimum sentences for drug use and possession. Infamously, the law established a 100:1 ratio for the punishment of crack and cocaine, so that possessing a single gram of crack was treated as harshly as possessing 100 grams of cocaine. Bias’s death had nothing to do with crack, but that didn’t matter to Congress or the media. Days before his death, Newsweek had already declared crack the biggest story since Watergate and Vietnam.

Hoffman’s death arrives at a similar moment in the nation’s relationship with heroin, a drug that’s undoubtedly “back,” if not “in style.” According to the Department of Health and Human Services, the estimated number of heroin users in the United States increased from 373,000 in 2007 to 669,000 in 2012. That roughly mirrors the growth rate during the last major heroin epidemic, from 1969 to 1974, when soldiers who got hooked on heroin in Vietnam returned home and helped push the total number of American users from 242,000 to 558,000. While deaths from heroin were stable throughout most of the 1990s and 2000s, between 2006 and 2010 they jumped 50 percent, from 2,000 per year to just over 3,000. That’s still small in comparison to the death toll from prescription opiates like hydrocodone (“norcos”) and oxycontin: they killed 16,000 people in 2010, four times as many as in 1999. The recent uptick in heroin use may be driven in part by a federal crackdown on pill mills, which has caused the street price of prescription opiates to spike even as the price of heroin has fallen to $6 a bag, thanks to expanded production in Mexico.

Thus, a “new” heroin epidemic allegedly has begun. Peter Shumlin, the progressive governor of Vermont, recently dedicated the entirety of his State of the State address to Vermont’s “full-blown heroin crisis,” noting that the number of heroin deaths there almost doubled in 2013 (though only from 9 to 17, which is still above average). In nearby Maine, Paul LePage, the eccentric, Tea-Party-backed governor, used his own State of the State address to draw attention to heroin abuse and to an epidemic of drug-addicted babies born in the state—7 percent of all births in 2012 he claimed, though he didn’t specify what portion came from heroin.

Shumlin marshaled these grim statistics in order to plea for increased funding for treatment centers; LePage seized on the suffering of infants in order to advocate harsher criminal penalties. The divergence is both instructive and worrisome. Getting more addicts in treatment—which is different from getting addicts off opiates—saves both money and lives. Ratcheting up criminal penalties, on the other hand, leads to more expenditure and more death.

Our natural impulse, inflamed by reality TV shows like Celebrity Rehab, Cops and Intervention, is to round up the bad guys—four arrests have already been made in the Hoffman case—and to save addicts through rehab and redemption: to exorcise the heroin demon through detoxification. Sorkin articulated this heroic approach when he wrote on Thursday in Time that Hoffman “did not die from an overdose of heroin—he died from heroin. We should stop implying that if he’d just taken the proper amount then everything would have been fine.”

Sorkin’s view is common and sounds logical—if heroin is a scourge, then the only solution is to get rid of it. As a medical matter and a matter of policy, though, he’s tragically mistaken. Although we won’t have all the relevant information until Hoffman’s toxicology report comes out, it’s virtually certain that Hoffman indeed died of an overdose of heroin. It’s equally certain that for millions of opiate addicts around the world, life can be manageable, if not exactly “fine,” if they get the right amount.

Opiate addiction is special. It can’t be treated in the same way as addiction to uppers like methamphetamine or cocaine. The basic difference is this: For coke and meth, rehab often works; for opiates—whether it’s heroin, oxycontin, hydrocodone, morphine, vicodin, fentanyl, buprenorphine or simple opium—it almost never does. Less than 40 percent of cocaine addicts relapse after leaving a rehab program. For opiate addicts, the figure is close to 100 percent. That’s because opiates physically transform the brain in a way that’s more powerful and difficult to reverse than addiction to other substances, and because addicts who skip even a single dose risk suffering agonizing symptoms of withdrawal (a.k.a. “dope sickness”).

From Hoffman’s behavior in the months leading up to his death, we know that he was seeking help and took his addiction seriously. “I’m a heroin addict,” is the way he introduced himself to a stranger at Sundance who asked Hoffman what he did for a living; onlookers confirmed that he appeared haggard and unrested. It’s also the way Hoffman introduced himself at the Narcotics Anonymous meetings he had been attending. Hoffman wasn’t in denial. He wasn’t shunning treatment. He wasn’t partying hard or “addicted to chaos,” as a contrite Lindsay Lohan admitted last year in an interview with Oprah Winfrey. He was addicted to heroin.

The media has emphasized Hoffman’s 23-year-clean streak and self-determination to check himself into rehab last year as part of the tragedy surrounding his death. “If he had survived without heroin so long, why did he suddenly relapse?” The reality is that while rehab can succeed at getting opiate addicts clean temporarily or even for years, it can also enhance an addict’s risk of dying. Because detoxification erodes an addict’s built-up tolerance for high doses of opiates, when someone relapses and shoots up with the old “normal” dose, the result can be death. (While the facts of Hoffman’s overdose seem to align with that narrative, the toxicology report will shed more light. For another highly publicized post-detox overdose, see Glee’s Cory Monteith, who died in a Vancouver hotel six weeks after leaving rehab.)

For the majority of addicts, the best strategy for leading a normal life is to go on some form of opioid maintenance. In the United States, the most common forms of maintenance are methadone and buprenorphine, which are less euphoric than heroin and ingested in pill form. Methadone is typically administered in a clinic, requiring daily attendance from addicts; buprenorphine is available via prescription, which is more convenient but also more easily leads to diversion to the black market, as with ordinary painkillers. One of the problems with methadone is that while it provides less of a rush than heroin, it can be just as deadly, especially if addicts supplement their daily methadone with street opiates (a common occurrence when the maintenance dose is too low). One advantage of buprenorphine is that it can be combined with naloxone, an opioid antagonist that makes it difficult to get high from other opiates (it can also prevent and reverse opiate overdoses when administered as an emergency measure). Police found a prescription buprenorphine bottle in Hoffman’s apartment, though it’s not yet known whether he was adhering to the medication. Of course, for some addicts—especially those resistant to other forms of treatment—the most successful maintenance therapy is simply heroin. Countries like Switzerland and Great Britain make heroin maintenance available—finding that for many the outcomes are superior and that “medicalizing” heroin in the manner of methadone makes it less attractive to young people.

With maintenance, many opiate addicts experience less disruption to their daily lives than people addicted to less-lethal but more crazy-making chemicals like crack or meth. Even with an uncontrolled addiction and a volatile supply of opiates, Hoffman was able to maintain a schedule and rate of productivity that would be challenging for most sober people. But that speaks to heroin’s chief paradox—while its use is less likely to publicly stigmatize you as an addict through erratic behaviors, it’s far more likely to kill you. Virtually every celebrity overdose involves some kind of opiate trigger. (Whitney Houston is an exception—along with Bias, she’s the rare celebrity who seems to have died of a more-or-less pure cocaine overdose.) If Hoffman had been adhering to a daily maintenance regimen of buprenorphine—i.e., if he had been taking what Sorkin dismisses as “the right amount” of opiate—he might have survived.

Whether Hoffman’s death will inspire a Rock-Hudson-like surge in sympathy for addicts or a Len-Bias-like surge in penalties for lawbreakers is an open question. As tributes continue to pour in from friends and fans around the world, we need to be vigilant about screening falsehoods and correcting myths. Hoffman’s death has the potential to end up saving lives, as he once had hoped. It also has the potential to end up claiming lives. Trying to rid the country of heroin, as Sorkin’s logic seems to advocate, is a fool’s errand that will engorge the black market and provoke riskier behavior from addicts. The first step of Narcotics Anonymous is to admit “we are powerless over our addictions, that our lives have become unmanageable.” In order to get control over the country’s heroin epidemic, we need to get control over how opiates are distributed. So far, maintenance is the only form of control we’ve discovered that works.

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